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        <title>申请可信验证-小马网</title> 
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					<form class="fr pr m-search" target="_blank" id="searchCredit" method="GET" action="##">
						<fieldset class="pa">
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										<a class="transd3 trans ell" href="http://www.ht.cn/" target="_blank">http://www.ht.cn/</a>
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  <div id="kiss_wrap">
                    
<div class="phone_apply_flow"></div>
<div class="body_wrap">
    <div class="kiss_form prebook_info">
        <form action="https://www.pinpaibao.com.cn/phone/submit_apply/" method="post" id="J_submit_apply" novalidate="novalidate">
            <input name="csrfmiddlewaretoken" value="QraFMvDgr1q4wKO5WzVhrN8O8GygVZeM" type="hidden">
            <div class="kiss_fm_area ">
                <input name="product_name" value="phone" type="hidden">
                
                <input name="property_channel" value="normal" type="hidden">
                
            </div>
            <div class="form_hd">申请可信验证</div>
            <div class="kiss_fm_row clearfix">
                <label class=" ">申请认证类型：</label>
                <div class="kiss_fm_area ">
                    <img src="../img/phone/hm_83x30.png" alt="" title=""> 
                </div>
            </div>
            <div class="kiss_fm_row clearfix organizer_location">
    <label class="s_lb" for="site_domain"><b class="mt"></b>所在地</label>
    <div class="kiss_fm_area ">
        <select class="fl" id="organizer_province" name="organizer_province">
            <option value="" selected="selected">---请选择省份---</option>
            
            <option value="北京">北京</option>
            
            <option value="上海">上海</option>
            
            <option value="天津">天津</option>
            
            <option value="重庆">重庆</option>
            
            <option value="河北">河北</option>
            
            <option value="山西">山西</option>
            
            <option value="内蒙古">内蒙古</option>
            
            <option value="黑龙江">黑龙江</option>
            
            <option value="吉林">吉林</option>
            
            <option value="辽宁">辽宁</option>
            
            <option value="山东">山东</option>
            
            <option value="河南">河南</option>
            
            <option value="陕西">陕西</option>
            
            <option value="甘肃">甘肃</option>
            
            <option value="青海">青海</option>
            
            <option value="新疆">新疆</option>
            
            <option value="宁夏">宁夏</option>
            
            <option value="西藏">西藏</option>
            
            <option value="四川">四川</option>
            
            <option value="云南">云南</option>
            
            <option value="贵州">贵州</option>
            
            <option value="湖北">湖北</option>
            
            <option value="湖南">湖南</option>
            
            <option value="广东">广东</option>
            
            <option value="广西">广西</option>
            
            <option value="福建">福建</option>
            
            <option value="江西">江西</option>
            
            <option value="江苏">江苏</option>
            
            <option value="浙江">浙江</option>
            
            <option value="安徽">安徽</option>
            
            <option value="海南">海南</option>
            
            <option value="香港">香港</option>
            
            <option value="澳门">澳门</option>
            
            <option value="台湾">台湾</option>
            
        </select>
        <select class="fl" id="organizer_city" name="organizer_city">
            <option value="" selected="selected">--请选择城市--</option>
            
        </select>
    </div>
</div>

            <div class="kiss_fm_row clearfix">
                <div class="kiss_fm_area">
                    <label for="verify_year">认证年限</label>
                    <select id="verify_year" name="property_year" class="valid">
                        <option value="1" selected="selected">1年</option>
                        <option value="2">2年</option>
                        <option value="3">3年</option>
                    </select>
                </div>
                <span class="price-toggle" style="height:32px;line-height:32px;margin-left:10px;color:#e25630">600元</span>
            </div>
            <div class="kiss_fm_row clearfix">
                <label class=" " for="id_verify_phone"><b class="mt"></b>验证申请的号码</label>
                <div class="kiss_fm_area ">
                    <input autocomplete="off" name="verify_phone" maxlength="15" class="" id="id_verify_phone" spellcheck="false" value="" type="text">
                </div>
            </div>
            

<div class="kiss_fm_row clearfix">
    
        
		<label class=" " for="id_applicant_name"><b class="mt"></b>申请人姓名</label>
        

        <div class="kiss_fm_area ">
            <input autocomplete="off" class="" id="id_applicant_name" maxlength="50" name="applicant_name" spellcheck="false" value="" type="text">
            

            

        </div>
    
</div>

            

<div class="kiss_fm_row clearfix">
    
        
		<label class=" " for="id_applicant_email"><b class="mt"></b>申请人邮箱</label>
        

        <div class="kiss_fm_area ">
            <input autocomplete="off" class="" id="id_applicant_email" maxlength="32" name="applicant_email" spellcheck="false" value="" type="text">
            

            

        </div>
    
</div>

            

<div class="kiss_fm_row clearfix">
    
        
		<label class=" " for="id_applicant_mobile"><b class="mt"></b>申请人手机号</label>
        

        <div class="kiss_fm_area ">
            <input autocomplete="off" class="" id="id_applicant_mobile" maxlength="11" name="applicant_mobile" spellcheck="false" value="" type="text">
            

            

        </div>
    
</div>

            <div class="fm_group"></div>
            <div class="fm_summ">
                
                <div class="kiss_fm_sb clearfix">
                    <a class="kiss_btn kiss_sbtn_red" href="javascript:" id="J_sb_form">提交并确认订单信息</a>
                </div>
            </div>
        </form>
    </div>
</div>


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